I am not fond of triangles to explain models, especially in the safety world. I also looked at three intersecting circles, which was better than the triangle but still not quite what I wanted. In the end I settled for the analogy of a milking stool. These three legged stools are very stable when all the legs are the same length, strength and are held together solidly by the seat part of the stool. If one leg fails, then it all turns bad, very quickly.
One leg is Event / Outcome Investigations, where we are trying to understand the gaps between the way work was done on the day, how others normally do the work and how our processes and procedures intend it to be done; and then we work to close the gaps we have identified.
The second leg represents what I will label Field Leadership. These are those activities (conversations actually) that leaders undertake in the field on a day-to-day basis with people doing tasks. The intent is to try to understand the gaps between the way work was done on the day, how others normally do the work and how our processes and procedures intend it to be done; and then we work to close the gaps we have identified.
And the third leg covers Fatal Risk Controls. These are those controls, often described as Critical Controls, that need to be implemented each and every time a task is undertaken to ensure that one of the outcomes of the task is not a fatality. The intent is to make sure we set up the way the work is intended to be done (the control) such that it is easy to do correctly, difficult to do incorrectly, and forms an essential component of the controls needed to create safety that is fatality free.
I will make the assumption that you have read and absorbed my recent blog entitled: “Thinking about how we think about Safety”. If not, I suggest you do, as it will explain some of the concepts I am using here (Such as ‘Work-As-Done’). (Click this link http://raeda.com.au/?p=223)
So, how best to summarize the three legs? What are the ideal states of the three legs? What questions could we ask to test whether it is being achieved? and what is the call to action/what should we do?
Event / Outcome Investigations:
Ideal State: Work-As-Done = Safe Work (Exploring what didn’t work)
Question to ask: What is driving the gap between Work-As-Done and Work-As-Intended?
Call to action: Close the gap between Work-As-Done and Work-As-Intended after an event.
Field Leadership:
Ideal State: Work-As-Done = Work-As-Intended (Checking out the real world)
Question to ask: What is driving the gap between Work-As-Done and Work-As-Intended?
Call to action: Close the gap between Work-As-Done and Work-As-Intended before an event.
Fatal Risk Controls:
Ideal State: Work-As-Intended = Safe Work (Setting up for success)
Question to ask: Will following Work-As-Intended ensure the Fatal Risk Controls are effective?
Call to action: Create (Fatal Risk) procedures, controls et cetera (Work-As-Intended) so that they are easy to follow correctly and difficult to follow incorrectly.
We know that the drivers of Work-As-Done and Safe Work include the following:
- Resilience
- Risk Intelligence, including within the individuals and the resultant risk management within the SOP, THA et cetera
- Procedural / task / situational complexity
- Task planning, including WYSIATI.
- Task assignment / Answering a different question
- Task completion / Plan Continuation / Intense Task Focus
- Effective core competencies, capacities and capabilities
So keeping an eye on all of that is a must. But what else can we do? What actions can we take? What behaviours can we exhibit to ensure it all comes together and the conversations we have within any of the three legs looks, sounds and feels the same?
- We can ensure that we always maintain a focus and are very interested in how work is actually being done and not just how we intend the work to be done (our SOPs).
- We can challenge our Procedures, SOPs, THAs et cetera to make sure they are setting our people up for success: Are they able to be followed? Are they simple? Do they make it easy to do things correctly and harder to do them incorrectly? Do they align with each other? Do they contain elements of Resilience? Do they explain the controls that must be implemented, and when? Are they written the way those who have to use them want them written? Are the critical controls from our fatal risks being verified by those who use them?
- As we build our Fatal Risk Controls, as we talk to people in the field, and as we investigate unexpected outcomes, we can use the same language, exploring any gaps between Work-As-Done and Work-As-Intended and work on closing the gaps with a passion.
- Coach our leaders to be effective coaches in order to help us all create safe work.
As I mentioned at the start, the strength and usability of a milking stool lies in the fact that all three legs need to be in good condition, the same length and strength and are held together by the seat part of the stool. What is the equivalent of that seat, the glue the holds this all together? I believe the answer is Coaching
We know that coaching and helping leaders become great coaches using a non-directive approach such as the GROW model helps enormously in the area of Field Leadership and Event Investigations, how can we also use it in the Fatal Risk space? I actually think it is exactly the same. My suggestion is to think about how you can create a coaching culture. Not only formal coaching of your leaders but helping them create a coaching style into their managing an leadership activities. Coaching can be used in just about any situation; When the team is building a bow-tie to describe a fatal risk, when you are out in the field being a great safety leader or when you are helping a team really understand an incident.
In summary, if our people, at all levels:
- Have the right capabilities, capacities and competencies,
- Are assigned tasks that are planned, thought through and clear,
- Understand the context and purpose of the task assigned to them,
- Understand how the job could be done to make it go right,
- Understand the likelihood of things going right (successful and safe completion of the task) and the likelihood of it going wrong,
- Understand what could go wrong, what to look for to indicate it might be going wrong and have a plan ready to implement when this happens,
- Be guided by simple, easy-to-use SOPs and THAs (Work-As-Intended) that reflect how work is actually done,
- Be supported by effective coaching by leaders, and
- Carry out the task as planned,
We WILL achieve safe work.